Etiology And Prognostic Factors Of Pediatric Acute Liver Failure

Objective:To study the etiology and related prognostic parameters of pediatric acute liver failure（PALF）.Materials and methods:Children admitted to the pediatric intensive care unit（PICU）in the First Hospital of Jilin University due to PALF from January 2011 to January 2022 were recruited.The clinical data were collected by electronic medical record system.The patients were divided into 4 groups according to etiology（infectious,medicine/drug toxicity,genetic metabolic and indetermined causes）and 2 groups according to outcome（survival and death）.The basic information,clinical data,complications and treatment in the different groups were compared.Results:1.Basic information: A total of 35 patients were included,with a male-to-female ratio of 2:3.The mortality rate was 34.3%（12/35）.In terms of age distribution,schoolage accounted for the majority of cases（48.6%）,followed by adolescence（17.1%）.Infancy,early childhood and preschool age accounted for 11.4% each.In terms of etiology,indetermined PALF（i PALF）（28.6%）was the most common cause of PALF,the second most common cause was genetic metabolic diseases（25.7%）,followed by infectious diseases（22.9%）and medicine/drug toxicity（17.1%）,genetic metabolic diseases and congenital developmental malformations were found in equal proportion（n=1,2.9%）.77.1% of subjects developed hepatic encephalopathy（HE）,the remaining complications included multiple organ syndrome dysfunction（MODS）（60%）,lung injury（54.3%）,thrombocytopenia（37.1%）and acute kidney injury（AKI）（17.1%）.94.3% of the cases underwent plasma exchange（PE）,62.9% received continuous renal replacement therapy（CRRT）,and 3 children performed liver transplantation（LT）.2.Differences among variable etiologies: the most common etiology in infants（75%）,early childhood（50%）and adolescents was i PALF.The etiology of children in the preschool period comprised infection,poisoning,congenital developmental malformations and i PALF（n=1,25%,each）.Genetic metabolic disease was the main cause in school-age children（35.3%）,statistically significant association of causes wasn’t shown among different ages（P=0.311）.Children with infectious PALF all began with fever,and PALF because of mushroom poisoning all began with digestive symptoms.The most common symptom at the onset of genetic metabolic diseases was digestive symptoms,while for children with i PALF at the onset of jaundice,different causes of PALF have different onset（P=0.001）.The highest and lowest median alanine transaminase（ALT）were present in i PALF and toxicity groups respectively,with statistically significant association among 4 groups（P=0.001）.Total bilirubin（TBIL）and international normalized ratio（INR）were not significantly different among 4groups（P>0.05）.There were no differences among these groups concerning HE,MODS,lung injury,and thrombocytopenia.Children in the infectious group were more likely to present AKI（62.5%）,there was no patients showed AKI in genetic metabolic and i PALF group,the proportion of concurrent AKI was comparable amon 4 groups（P=0.002）.In terms of treatment,the PE frequency patients in genetic metabolic group and the i PALF group were higher（P=0.004）,and there was no significant difference seen in the use of CRRT,mechanical ventilation,and vasopressor among groups（P>0.05）.Survival rate of participants in each group did not differ significantly（P>0.05）.3.Comparisons between survivors and nonsurvivors: The mean PICU and total length of hospital stay in survivors were higher than those in nonsurvivors（P<0.05）.Pediatric risk of mortality（PRISM）score and the related biochemical parameters（ALT,TBIL,INR）were significantly lower in survivors.There were no significant differences in AKI,HE,MODS,and thrombocytopenia.The incidence of lung injury was significantly higher in nonsurvivors than that in survivors（91.7% vs 34.8%,P=0.001）.The median number of PE sessions in both groups was 2（P=0.070）,more patients received CRRT in death group（56.5% vs 75.0%,P=0.481）.Other interventions,such as mechanical ventilation（39.1% vs 83.3%,P=0.013）and vasopressor（30.4% vs66.7%,P=0.040）in survivals were lower than that in nonsurvivors.Conclusion:1.The onset forms and median ALT are different in different etiology,and PALF caused by infections is more likely to present AKI.2.High PRISM score,ALT,TBIL and INR,lung injury,the use of mechanical ventilation and vasopressors could be potential markers for predicting mortality in PALF.